Medical Coding and Medical Billing - New Codes!

I thought you might be interested in some additions in the ICD -10, the newly updated (the last one, ICD-9, was published some 30 years ago) tenth version of the International Classification of Diseases which is published by the World Health Organization.  It is the standard for coding diagnoses and procedures that physicians must use when filing for reimbursement from Medicare and other insurance companies.  The current coding system, according to an article in the recent issue of The Weekly Standard, will increase the number of accepted diagnoses from 17,000 to 155,000!!

Medical coding has become a specialty of its own.  Medical facilities and physicians offices employ individuals who have become certified in this "specialty."  The recent edition of the new ICD-10 regulations was discussed at a meeting of the American Academy of Professional Coders.  Yes, this specialty now has its own special "Academy."

Here, believe it or not, are some of the new ICD-10 Codes:

Code T63112A - Toxic effect of venom of gila monster
Code V9412XA - Bather struck by non powered watercraft
Code X060XXA - Exposure to ignition of plastic jewelry
Code T63612A - Toxic effect of intact with Portugese Man-o-War
Code S30867A - Insect bite (non-venomous) of anus
Code W5612XA - Struck by sea lion
Code T71222A - Asphyxiation due to being trapped in a car trunk
Code R461 - Bizarre personal appearance
Code V9542XA - Forced landing of spacecraft injuring occupant
Code V9733XA - Sucked into jet engine
Code V80731A - Occupant of animal-drawn vehicle injured in collision with streetcar

Estimated cost of implementing new code for a small medial practice is $83,290, and for a very large practice - $2.7 million!

Addressing Both Sides of the Israeli - Palestinian Issue

Today's NY Times (Feb 27) includes a story describing the rescinding of an invitation to Professor Rashid Khalidi to address the student Ramaz Political Society, a group of Ramaz high school students.  The head of the Jewish modern orthodox school, Paul Shaviv, felt that "any dialogue between the professor and students would be imbalanced."  "'It would be a bit like inviting the head of our high school tennis team to play an exhibition match with Andre Agassi.'"  He apparently considered Ramaz high school students not astute enough to enter into dialogue with this renowned and respected pro-Palestinian speaker.

This follows efforts of other Jewish organizations dedicated to Zionism to inhibit or interfere with local chapters of such groups engaging speakers that propose a different view of the Middle East problem, especially speakers, most often Jewish, who support the BDS (Boycott, Divestment, Sanction).  Such actions are and will continue to be counter-productive.

Attempts to suppress the views of opposing factions in a debate can only reflect poorly on those involved in the censorship.  In fact, pro-Israel organizations should encourage invitations to dissenters to address them.  There should be no fear of hearing the words and opinions of those on the other side - they should be welcomed and openly debated.

The Logic About Abortion - Whether Pro-Choice or Pro-Life

Wendy Davis,  "liberal" candidate for governor of Texas, who gained fame as a state legislator for her filibuster of state abortion restrictions, has modified her stand, saying she is opposed to late term (after 20 weeks) abortion except in cases of rape or incest, or when the mother's life is at risk.   Apparently, according to Ms. Davis, there is a point where a fetus has a "right to life."

Let's take a look at this issue once again.

A fetus (here defined as any product of conception) either has "a right to life" or it does not.

If it does not have a "right to life,"  abortion may be performed at any point prior to birth.

If a fetus has a "right to life," then this right either begins at conception or some time thereafter.

If it begins at conception - end of discussion.  Abortion for the sake of abortion would be immoral - rape, incest, or other crimes can have no bearing on this decision.  Once a fetus has attained "the right to life," the subsequent denial of that right cannot be modified because of the means of fetal generation.

If a "right to life" begins at some point after conception, then abortion for the sake of abortion is immoral at that time and thereafter - rape, incest or other crimes can have no moral effect on this decision.  Once a fetus has attained the "right to life," the subsequent denial of that right cannot be modified because of the means of fetal generation.

When the right to life is said to occur at some point after fertilization, that point needs to be defined.  It is generally considered to be the age of "viability"-  the age at which the fetus is considered able to sustain life ex-utero (outside the uterus.)  However, not all fetuses may attain viability at the same in-utero age.  Just as ex-utero "normal" infants don't all mature at the same rate - so it would be for in-utero fetuses.

Viability ex-utero is not defined by the ability of a "born" infant to survive without the assistance of technology.  The need for technological assistance to sustain life is, in fact, the rule rather than the exception in children born prematurely.  It must be acknowledged that the fetal age of ex-utero viability may decrease with advancement in this technology.  With time, future technology may progress to the point where ex-utero viability may extend very close to, or actually to, the onset of fertilization!

Some interesting further considerations:

If you believe that rape or incest justify abortion, consider the rare cases of "superfecundation."  Superfecundation is the fertilization of two or more ova from the same cycle by sperm from separate acts of sexual intercourse.  If one ovum was fertilized because of rape or incest, and the other through "mutual non-incestuous consent," which fetus should be aborted - one, both?  Should there be DNA testing to make that determination?

Is a fetus truly a "part of the mother's body" to which she has full control?  A fetus is genetically distinct from its mother and from its father.  If a mother is to have full control of her body, including control over a genetically distinct entity within, then she could logically abort a fetus at any age.  There could be no moral distinction between abortion at 6 weeks and abortion at 34 weeks.  One cannot lose this "right to my body" as that part of the "body" develops over time.

If a woman accepts the implant of a fetus from another couple which, therefore, is not genetically related to her at all, does this fetus become part of her body as well?  Does she have the moral right to make decisions regarding this fetus who entered her body from without rather than from within?  Or does the "right to my body" not apply in such cases.

If the life of a mother is potentially compromised by an ongoing pregnancy and one must make the "Solomonic" choice as to which of the two shall survive - this decision should be in the hands of the concerned individuals who are legally and ethically involved.  Decisions may be based on moral and/or religious beliefs or tenets.  Such judgments are always extraordinarily difficult - and non-involved parties should not have the right to impose them on the concerned parties.

Conclusion:

If you are "pro-choice" you must be pro-choice in all situations.  It does not follow that exceptions apply except where the Solomonic decision is required.

If you are "pro-life" you must be pro-life in all situations.  It does not follow that exceptions apply except where the Solomonic decision is required.

The False Constancy of Inherited Guilt - Israel, Germany and Victimhood

“Silence in the face of false propaganda legitimizes actions against Israelis. I will not accept false moralizing against the people of Israel, in Israel’s Knesset. Certainly not in German.”

“His support for Palestinians who incite for the destruction of Israel, from the Knesset podium, 70 years after the Holocaust, is a chutzpah without parallel.” 

The Times of Israel (a web-based English-language Israeli newspaper) included these quotes in its article describing the reaction of right wing members of the Israeli Knesset (Parliament) and their subsequent walking out on the President of the European Union, Martin Shulz, during his  address to the Knesset (apparently in his native German).

These words are far more than mere criticism of Mr. Schulz's remarks.  They continue the process of using Jewish victimhood during the Third Reich as a modifier, if not justifier, of Israel's existence today.  This is not right.  Recently many speeches have been made and books written, including Yascha Mounk's current thoughtful and disturbing "Stranger in My Own Country," discussing the German-Jewish issues that continue to besiege this unique relationship - the never-ending accusations of evident "inherited guilt" now beginning to beleaguer a fourth generation of the Germans born after World War II.

Constant accusations of guilt towards grandchildren and great-grandchildren of perpetrators is having more negative than positive effect - as would be expected.  The time of repeated reference to Holocaust and victimhood during political debates should be over.  Right wing (or any other) parties wishing to inveigh against a European or German point of view towards Israel should do so without such allusion.

Israel - Then and Now

Rhonda and I have just returned from a 10-day trip to Israel - a trip designed for "first-timers."  Now though Rhonda was a first-timer, I was actually a "third-timer," having visited Israel in 1966 and 1980.  When I visited as a "first-timer" I was in my late 20's and Israel was 18.   How did my sense of the country change over this 48-year span.

I still remember the words of our guide Max, in 1966, as he addressed our group on entering Tel Aviv after having landed at Lod Airport.  He pointed out to us (a group of US Military officers) that the people cleaning the streets were Jewish, even the criminals were Jewish and, yes, the prostitutes were also Jewish!  There was no West Bank. There was no East Jerusalem to visit. There was no Western Wall to approach  There were armed Jordanian soldiers readily visible in towers overlooking us as we walked the streets of Israeli Jerusalem.  Most of the Israelis we met were European by birth.  So many questioned why we were still part of the Diaspora and refused to emigrate to the State of Israel.  Israelis would accost us in the streets to lecture us, with a classically Israeli uninvited insistence, that the place for Jews was Israel - all Jews should feel an obligation to emigrate.   I felt disrespected as a Jewish-American.  I was made to feel less Jewish, made to feel that Israelis did not consider me a committed Jew unless I committed to an intention to emigrate.  I was clearly uncomfortable.

Fast forward to 2014.  I'm in my mid-70's and Israel is 66.  It's a different place - not only physically, but also in its sociologic and self-sustaining evolution.  I'm also a different "place" - not only physically but also in my sociologic and self-sustaining evolution.   Israeli "street cleaners" do not appear to be Jewish (I must admit, I did not knowingly meet any prostitutes, so can't be sure about their backgrounds) and  there are noticeably now people of color!  The cities seem much more cosmopolitan.

That sense of being a derided, uncommitted Diaspora Jew was no longer.  No one encouraged emigration.  No one even suggested it.  Diaspora Jews were Diaspora Jews and Israelis were Israelis!  We have a common history, but not necessarily a common commitment.  That's good.  A feeling of Israeli "dependency" no longer existed.  The word "miracle" is often used in describing this extraordinary, vibrant country.  "Miracle" is a word that I find hard to accept in describing anything, but somehow the word may apply here.  I venture to say that if there is such a thing as a "miracle," Israel may be the unique paradigm.

Israel - Mature, Modern, Madcap, Majestic, and - simply aMazing!

A Fetal Life in a Dead Mother

A woman who is legally dead, is being kept on "life support" in a Texas hospital against the wishes of her husband and parents.  She is being maintained on "life support" solely to sustain the viability of her 21-week old fetus.  Physicians have refused to honor the wishes of the family, arguing that Texas law prevents them from withholding "life-sustaining treatment" from a pregnant patient.  The family contends, however, that since the mother has been declared "brain-dead" she can no longer be considered a pregnant patient, since a "patient," by definition, is someone who is alive.  Physicians intend to continue the present regimen until the fetus has reached the age when a caesarian section can be performed.

This fetus is now approaching extra-uterine viability - a fact which makes this case difficult to morally adjudicate.  However, if the fetus were as little as 4 weeks of gestational age, or if the fetus were as much as 30 weeks gestational age, how one would feel about this tragic set of events might be quite different.

If the fetus is to be the sole consideration here, then perhaps a caesarian section should not even be considered, there being no question that a fetus has a far better chance of survival in-utero than ex-utero.  Assuming no complicating medical factors, would it be ethical to continue to maintain this "natural" form of fetal nurturing rather than proceeding with a C-section?  Would it be ethical at 4 weeks gestation?  Would it be ethical at 30 weeks gestation?

Whose Medical Record Is It Anyway!

A recent article in the prestigious New England Journal of Medicine discusses the usefulness of giving patients full access to their medical records, including the physicians "notes," which had previously remained inaccessible.

A medical record includes laboratory results, radiology results and pathology results - all of which I concur should be made available to a patient - after all, they are his lab results, his radiology results, and his pathology results.  However,  it had always been my feeling that what I entered into a medical record (my "notes") was only for my eyes and for other eyes to which I wished to show them.  And when I translated these notes into a formal letter, most commonly to a referring colleague, the letter was a private communication between my colleague and me.

Medical record "notes" often contained personal reflections on the patient, possibly his family, his attitude, and maybe even some quirky anecdotes to help recall a a previous encounter.  I never regarded my "notes" like those that would be part of a personnel record or subject to the Freedom of Information Act.

But I guess those are bygone days.  Now, were I to enter information into a patient's record - it would be limited to "the facts." Any "color" would have to be withheld from the written record and restricted to some non-written form of communication (if deemed necessary).

Progress - onward and upward.